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Palliative RT in Lung Cancer-ASTRO guidelines

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  • 1. Palliative Thoracic Radiation Therapy in Lung Cancer : ASTRO Guidelines Mayur Mayank
  • 2. Reference : 17-12-2013 2
  • 3. • • • • Introduction Methods and materials Results Conclusions 17-12-2013 3
  • 4. INTRODUCTION • Palliative Thoracic Radiation therapy is used often in patients with Metastatic lung cancer or advanced lung cancer. • It is used for : – Symptomatic relief : hemoptysis, bronchial obstruction, cough, shortness of breath, and chest pain – To improve health related quality of life (QOL) 17-12-2013 4
  • 5. INTRODUCTION • The major question addressed by most of the randomized control trials (RCT’s), meta analyses and systemic reviews have been : – External beam radiation therapy (EBRT) dose fractionation – Use of Endobronchial brachytherapy (EBB) in initial or salvage management, and – Use of concurrent chemotherapy (CC) with palliative radiation therapy 17-12-2013 5
  • 6. INTRODUCTION • To address the above mentioned 3 issues, ASTRO Clinical Affairs and Quality Committee convened a Task Force of experts in the field of Lung cancer (LC) to develop a guideline on the use of radiotherapy in the thoracic palliation of LC with EBRT, EBB, and CC with radiotherapy. 17-12-2013 6
  • 7. METHODS AND MATERIALS • The Guidelines Subcommittee of the ASTRO Clinical Affairs and Quality Committee (CAQC) identified the use of palliative radiotherapy as it is applied to LC as a highpriority topic needing an evidence-based guideline. • The Board of Directors authorized creation of a Task Force to study issues related to the use of radiotherapy in the treatment of LC and approved its membership, which included 7 recognized experts in LC radiation oncology, 1 in radiation oncology/pulmonology/community practice, 1 representative from the Guidelines Subcommittee of the CAQC, 1 medical oncologist, and 1 radiation oncology resident. 17-12-2013 7
  • 8. METHODS AND MATERIALS • The TF was to review and synthesize currently available evidence to develop a clinically practical, evidence-based guideline to help radiation oncologists and LC patients to determine the appropriate use of EBRT, EBB, and concurrent palliative chemo radiotherapy for palliative intent LC patients. • The members of the Task Force divided into 3 subgroups to address separate questions based upon their particular areas of expertise. 17-12-2013 8
  • 9. METHODS AND MATERIALS • A literature search strategy was developed around the 3 practice guideline questions of EBRT dose fractionation, indications for EBB, and use of CC with palliative intent radiotherapy. • Search strategies were performed on Pub Med assessing possible articles from 1966 to March 1, 2010 focusing on RCT’s , meta analyses and systemic reviews addressing the three questions. 17-12-2013 9
  • 10. RESULTS 1. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? 17-12-2013 10
  • 11. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? – Indications for thoracic EBRT include, but are not limited to: hemoptysis, cough, chest pain, dyspnoea, obstructive pneumonia, dysphagia related to esophageal compression, superior vena cava syndrome, hoarseness, or stridor. – Symptoms caused by malignant pleural effusion, lymphangitic carcinomatosis, and multilobar parenchymal disease typically are not suitable for palliative thoracic EBRT. 17-12-2013 11
  • 12. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? • There have been 14 RCTs published to date addressing the question of the optimal EBRT dose schedule to palliate symptomatic advanced LC. • These 14 studies were heterogeneous by the dose regimens used, the performance status, the age of patients accrued, and the selection and reporting of outcomes 17-12-2013 12
  • 13. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? • A comprehensive review of these trials was completed in 2006 and updated in 2009 with no change in conclusions, by the Cochrane Collaboration. • A 2008 review and a recent 2010 review have also arrived at similar conclusions. 17-12-2013 13
  • 14. 17-12-2013 14
  • 15. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? • The Cochrane conclusions were as follows: 1. There was no strong evidence favouring 1 EBRT schedule over another with respect to efficacy of palliation 2. Acute toxicity was greater with higher dose regimens 3. patients with better performance status might have a survival benefit with the higher dose regimens (5% at 1 year and 3% at 2 years) 4. radiation myelopathy may be associated with some regimens (eg, 17 Gy/2 fractions), requiring appropriate RT planning. 17-12-2013 15
  • 16. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? • To summarize : – Higher dose radiation treatment fractionations are associated with improvement in total symptom score and survival, esp. in patients with good performance status. – The specific high-dose fractionation schedule to optimize the therapeutic ratio between improvements in total symptom score/survival and minimization of normal tissue effects such as radiation esophagitis is currently unknown. 17-12-2013 16
  • 17. What is the optimal dose/fractionation schedule for thoracic palliative EBRT in patients with LC? – shorter fractionation schedules (eg, 20 Gy in 5 fractions, 17 Gy in 2 fractions, and 10 Gy in 1 fraction) also provide good symptomatic relief and can be used for patients requesting shorter total treatment courses and also for patients with poor performance status. 17-12-2013 17
  • 18. RESULTS 2. What is the role of EBB alone or in conjunction with other modalities (including EBRT) in both the initial and salvage palliative management of LC? 17-12-2013 18
  • 19. What is the role of EBB alone or in conjunction with other modalities (including EBRT) in both the initial and salvage palliative management of LC? • It is possible to treat a tumour in the bronchus through the placement of endobronchial catheters. • The goal of such therapy is the relief of endobronchial symptoms such as cough, shortness of breath, and hemoptysis. • EBB cannot be used to treat extrabronchial disease or disease in the lung parenchyma. 17-12-2013 19
  • 20. What is the role of EBB alone or in conjunction with other modalities (including EBRT) in both the initial and salvage palliative management of LC? • The literature search identified 6 RCTs that have evaluated the palliative role of EBB in LC. • There are only 426 patients represented on the aforementioned studies, with no individual RCT having sufficient numbers to draw definite conclusions. • It is evident that addition of EBB does not improve survival in patients with LC. 17-12-2013 20
  • 21. 17-12-2013 21
  • 22. What is the role of EBB alone or in conjunction with other modalities (including EBRT) in both the initial and salvage palliative management of LC? • A recent Cochrane systematic review of 13 RCTs came to similar conclusions: – EBRT is superior to EBB for the initial palliation of symptoms, – there is no added benefit to EBRT plus EBB over EBRT alone or with EBB versus EBRT and Nd-YAG laser. 17-12-2013 22
  • 23. What is the role of EBB alone or in conjunction with other modalities (including EBRT) in both the initial and salvage palliative management of LC? • However, EBB remains a reasonable therapeutic manoeuvre, when feasible, in patients who would have failed previous EBRT and now present with recurrent bronchial obstruction or hemoptysis and/or in selected patients presenting with initial lung obstruction in the setting of nonmetastatic endobronchial disease. • The goal of the EBB in the latter group would be to potentially re-expand the lung before or in conjunction with radical dose radiotherapy, if clinically appropriate. 17-12-2013 23
  • 24. What is the role of EBB alone or in conjunction with other modalities (including EBRT) in both the initial and salvage palliative management of LC? • No ideal EBB dose prescription regimen has been identified in the literature for either EBB after EBRT or for initial management in cases of lung obstruction with non metastatic disease. 17-12-2013 24
  • 25. RESULTS 3. What is the role of chemotherapy administered concurrently with radiation for the palliation of LC? 17-12-2013 25
  • 26. What is the role of chemotherapy administered concurrently with radiation for the palliation of LC? • Systemic chemotherapy has become a standard of care for patients with metastatic or recurrent NSCLC. • Several randomized studies have demonstrated that, when compared with best supportive care (BSC), chemotherapy not only significantly improves survival but also reduces symptoms and enhances QoL. • In patients with locally advanced NSCLC, intact PS, and limited weight loss, several RCTs have shown an advantage for the use of concurrent chemo radiation over sequential therapies. 17-12-2013 26
  • 27. What is the role of chemotherapy administered concurrently with radiation for the palliation of LC? • However, addition of chemotherapy to radiotherapy increases the toxicity and the risk/ benefit analysis has to be done prior to integration of the two. • At this time, there is no added benefit for the use of chemotherapy concurrently with radiation therapy (RT) in the palliation of thoracic symptoms in lung cancer patients. 17-12-2013 27
  • 28. What is the role of chemotherapy administered concurrently with radiation for the palliation of LC? • There is 1 randomized phase III study directly addressing this issue. This study showed that, although the addition of chemotherapy to RT increased the overall response rate, this small benefit came at the cost of significant increased toxicity with no significant improvement in overall survival, progression-free survival, or symptom palliation. • All other studies have been phase I/II studies, which have also not shown much benefit in combining the two modalities together. 17-12-2013 28
  • 29. 17-12-2013 29
  • 30. What is the role of chemotherapy administered concurrently with radiation for the palliation of LC? • Studies to date have suggested that the benefit/risk ratio does not support the addition of chemotherapy concomitantly with radiation for the palliation of LC, primarily because of concerns regarding toxicity and no clear evidence that symptom palliation is improved. • In patients receiving palliative chemotherapy, the goal should be to optimally sequence or integrate courses of chemotherapy and RT in a non concurrent fashion to palliate lung symptoms as clinically indicated. 17-12-2013 30
  • 31. CONCLUSIONS • Patients with good performance status may benefit from higher dose/fractionation EBRT palliation with modest observed survival benefit. • Patients can also benefit with shorter schedules with less toxicity, in cases of poor performance status. 17-12-2013 31
  • 32. CONCLUSIONS • There is no defined role of endobronchial brachytherapy for routine initial palliative treatment. • However, it can be used for palliation of symptoms caused by endobronchial lesions in EBRT failure or for patients who require lung re expansion before or in conjugation with radical RT. 17-12-2013 32
  • 33. CONCLUSIONS • There is no role of concurrent chemotherapy with radiotherapy presently in the palliative setting in view of increased toxicity with no benefit. 17-12-2013 33
  • 34. THANK YOU !!! 17-12-2013 34